Do women’s attitudes towards abortion
and contraceptive methods influence their
option for sterilization?
As atitudes das mulheres em relação ao aborto e
ao uso de métodos anticoncepcionais influenciam
na sua opção pela esterilização?
1 Departamento de Medicina Social, Faculdade de Medicina de Ribeirão Preto, Hospital das Clínicas. Av. dos Bandeirantes 3900, Ribeirão Preto, SP 14049-900, Brazil.
Elisabeth Meloni Vieira 1
Abstract This paper analyzes the attitudes of low-income women towards abortion and con-traception. A survey was conducted in 1992 with a total of 3,149 childbearing-age women living on the outskirts of the Greater Metropolitan São Paulo Area. The study focuses on a sub-sample of 583 women. Attitudes of sterilized and non-sterilized women are compared. Women, especial-ly those sterilized, found the most important attribute of a contraceptive method to be its effec-tiveness. Women currently taking the pill were less likely than those sterilized to agree that steril-ization was the best method because of its effectiveness. Sterilized women were less likely than non-sterilized women to trust the pill. Sterilized women were more likely than non-sterilized to have reported adverse effects from the pill. Most women found abortion unacceptable except in the case of risk to the woman’s life. Women using more effective methods showed stronger nega-tive attitudes towards abortion. The tendency to be sterilized while still young was associated with more negative attitudes towards abortion. Family planning activities in basic health care services should include individual counseling for contraceptive use.
Key words Family planning; Contraception; Attitudes; Abortion
Resumo Este artigo analisa as atitudes em relação ao aborto e uso de métodos anticoncep-cionais entre mulheres de baixa renda moradoras da periferia da região metropolitana de São Paulo. Uma subamostra de 583 mulheres participantes uma pesquisa realizada em 1992 é exa-minada, mostrando que o mais importante atributo de um método contraceptivo é a sua efetivi-dade, especialmente para as esterilizadas. As mulheres que tomavam pílula tinham menor chance de concordar que o melhor método era a esterilização, por causa de sua efetividade. Mu-lheres esterilizadas, comparadas às usuárias da pílula, tinham menos chance de confiar na pílu-la e repílu-lataram efeitos adversos causados pelo uso do anticoncepcional. Muitas acham o aborto inaceitável, exceto nos casos em que há risco de vida para a mulher. Mulheres que usam métodos mais efetivos mostraram ter atitudes mais fortes contra o aborto. A tendência para submeter-se à esterilização mais jovem foi encontrada associada com atitudes mais negativas em relação ao aborto. As atividades de planejamento familiar no sistema de atenção primária à saúde deveri-am incluir o aconselhdeveri-amento individual para o uso de contraceptivos.
Introduction
According to the most recent Brazilian Demo-graphic and Health Survey (DHS), conducted in 1996, 76.7% of childbearing-age married women were using some form of contracep-tion, amongst whom 40% were sterilized (BE-MFAM/Macro, 1997). The issue of sterilization has been well studied over the last few decades from a number of demographic, public-health, social, and anthropological perspectives (Mi-nella, 1998). Interest in the subject arose after the rapid decline in fertility in Brazil starting in the 1970s, especially since the country had nev-er adopted an official birth control policy. Fam-ily planning was supposed to have been pro-vided officially by the public health care system since 1983. However, legal regulation of family planning did not occur until 1997, despite the new Federal Constitution of 1988 stating that it was a basic citizen’s right.
Only two contraceptive methods are preva-lent in the country: female sterilization (40%) and the pill (20.7%), indicating that family plan-ning services are grossly inadequate. Several studies of the public health system have shown that the main problems in family planning pro-vision are the lack of contraceptives, lack of properly trained health professionals, and in-sufficient family planning information (Villela et al., 1988; Costa, 1992; WHO, 1994).
It has been suggested that female steriliza-tion is a response to the lack of alternative methods and the dangers of illegal abortion. In fact, according to some authors, female steril-ization has occupied a void left by the lack of other contraceptive options and proper infor-mation on human reproduction and contra-ception (Barroso, 1988; Berquó, 1989). The problem with family planning in Brazil relates not only to the predominance of sterilization and the pill, i.e., the very provision of methods itself is inappropriate. Oral contraceptives have been marketed at low prices and have been available in pharmacies since the 1960s. Pills are sold with no prescription, counseling, or medical supervision (Costa et al., 1990). Other authors have emphasized that choices of con-traceptives are inadequate. According to a study in São Paulo, 40% of women on the pill presented risk factors (Hardy et al., 1991) and a Demographic Health Survey showed that 90.5% of them buy the product directly over the counter (BEMFAM/Macro, 1997).
The absence of formal regulation led to a situation in which sterilization has been widely but clandestinely practiced (Vieira, 1994; Vieira & Ford, 1995). The lack of records impedes
ef-fective control of the procedure by the public health system (Barros et al., 1991), while the fact that tubal ligations are performed in com-bination with unnecessary cesarean sections increases the risk of maternal morbidity and mortality (Faúndes & Cecatti, 1993). According to a study in São Paulo, one-third of maternal deaths were associated with unnecessary ce-sarean sections (Volochko, 1992).
New family planning legislation (Federal Act 9,263) was approved in August 1997, and the Ministry of Health published guidelines on procedures in November 1997 (MS, 1997), which were subsequently recognized as cov-ered by the Unified Health System (SUS). Some authors have argued that a “culture of steriliza-tion” ensued (Berquó, 1993) and that women “naturally” expect to end their reproductive cy-cle with tubal ligation (Citelli, 1998). A study on regret after sterilization found that the inde-pendent variable “history of problems with re-versible contraceptives” was among the factors leading women to undergo sterilization at an early age (Vieira, 1994; Vieira & Ford, 1996; Vieira, 1997). This paper analyzes attitudes to-wards contraception, including abortion, as factors influencing women to submit to steril-ization. Prior experience with contraceptives is taken into account as an important background variable for women’s choice.
Material and methods
on attitudes towards abortion was constructed and analyzed as a Likert scale and scored in or-der to be represented as a single variable.
Data were processed and analyzed using the SPSS-PC+ program. The analysis includes fre-quency distribution of the main variables and testing of hypotheses at the bivariate level us-ing the chi-square test. The null hypothesis was accepted if p < 0.05.
Results
In the sample of 3,149 women, many had start-ed marital relationships at a fairly young age. Approximately 20% of women from 15 to 19 years of age and 60% of those from 20 to 24 were already married. Sixty percent of all women from 15 to 49 years of age used contraceptive methods. The most frequently used method was the pill (26%), and the second most com-mon was female sterilization (22%). All other methods combined totaled 12% of respon-dents, while 40% were not using any form of contraception.
Marital union is strongly associated with contraceptive use, i.e., 80% of women in mari-tal relationships were using a family planning method as compared to only 15% of single women. Among married women the most fre-quently used method was the pill (34.4%) and the second was female sterilization (29.2%). Women under 30 preferred the pill, while ster-ilization was the most frequently used method among women 30 or older. Some 51% of steril-ized women were under 30.
The sub-sample consisted of 583 women. Most (74.4%) were between the ages of 20 and 39, with 217 (37.4%) from 20 to 29 and 215 (37%) from 30 to 39; only 5.7% (33) were 15 to 19 years old and 19.9% (116) aged 40-49. Most of the women, 535 (92%), were married or living in a consensual union and only 48 (8%) were not living with a male partner. Nearly all of the women (99%) were using some form of contra-ception. Of these, 40.8% (236) were on the pill, 40% (231) were sterilized, and the remaining 19.1% (111) were using other methods (coitus interruptus 5.5%, condoms 4.2%, vasectomy 3.6%, rhythm 1.9%, injectables 1.9%, IUDs 1.0%, and other methods 1.0%).
Contraceptive methods
Seven statements regarding contraceptive methods were read to the respondents for them to agree or disagree. The results are shown in Table 1.
The strongest agreement (76.2%) was with the statement that a contraceptive method’s most important attribute is its effectiveness. This was followed by the statement that steril-ization is the best method because it never fails (to which 73.7% agreed).
Many women reported side effects from the pill, and 65.5% of the respondents agreed with this statement. Some 60.4% said that their hus-bands did not agree to use condoms, and 58.5% did believe that the pill was totally reli-able. Although 37.7% said they did not trust the method they were currently using, this state-ment also showed the highest level of disagree-ment (42.7%). The statedisagree-ment with which the most women neither agreed nor disagreed (33.6%) was, “I prefer that my husband not use condoms because they interfere with
inter-course.”This suggests that many women did
not know how to respond to the statement, probably because they had never used condoms with their partners during intercourse. This re-sult is consistent with the low frequency of condom use in the sample, i.e., only about 4%. Women using the pill and other methods reported trusting these methods less than ster-ilized women did sterilization. About 27.7% of sterilized women agreed with statement num-ber 1: “I am currently using a contraceptive method, but I do not trust it very much to pre-vent pregnancy”, whereas 40.7% of women us-ing the pill and 51.7% of women usus-ing other contraceptives agreed with it. The difference was statistically significant (Table 2).
There was a positive association between agreement with statement number 1 and early age (p<0.005). Among women under 30, 45.6% agreed with this statement, whereas only 32% of women 30 or over agreed with it (data not shown).
The relationship between the two variables (trust in the current contraceptive method and contraceptive used) was controlled by the age variable, since there is a known association be-tween age and contraceptive use among this population. This association was present only for women 30 or older (p<0.0006). Only 26.5% of sterilized women 30 or older agreed with statement number 1, whereas 40.5% of women using the pill or other methods agreed with the statement. This means that women 30 or older on the pill or other methods were less likely to trust their current method as compared to ster-ilized women. It also indicates that the pill’s perceived unreliability is not as important for women under 30.
statement number 2: “My husband does not agree to condom use.”About 37% of women us-ing other contraceptive methods disagreed, while 22% of women on the pill and 17.7% of sterilized women disagreed with this statement (Table 2).
Women using the pill (91.5%) were more likely to require effectiveness from their cur-rent method and less likely to be unsure about statement number 3: “A contraceptive method’s most important attribute is its effectiveness.”
The difference between women on the pill and the other two groups, sterilized women (87%) and those using other methods (86%), was sta-tistically significant (Table 2).
Sterilized women were more likely to agree with statement number 4: “I don’t like taking the pill because it makes me sick”, than women who were actually taking the pill or using other methods. Half (50.4%) of the women taking the pill agreed with this statement, while three quarters of the sterilized women (77.5%) and those using other methods (72.4%) agreed with the statement (Table 2). There was a significant association between the answer to this state-ment and the respondent’s age. Women 30 or older were more likely to agree with statement number 4 (Table 3). This can be explained by the association between use of the pill among women under 30 and sterilization in women 30
or older. The association remained for both age groups after controlling for age, suggesting that side effects from the pill were an important fac-tor for sterilization (Table 3).
Women using the pill or other methods were less likely to agree with statement number 5:
“Sterilization is the best contraceptive method because it never fails”(25.8% and 22.4%, re-spectively, compared to 12.1%) (Table 2).
Sterilized women were less likely to trust the pill than women who were actually on the pill or using another method. Table 2 shows the relationship between statement number 6, “I don’t believe that the pill is totally reliable in preventing pregnancy”, and the contraceptive method actually used. About 67% of sterilized women agreed with this statement, as com-pared to 56% of women on the pill.
Abortion
Eight statements related to abortion were read to the same respondents, and the results are shown in Table 4. A full 82.8% of the respon-dents strongly agreed that abortion is a serious sin, and 72% responded that they would not terminate a pregnancy even if having a child would mean a disaster in their lives. About 69% of women strongly disagreed that abortion should be accessible to every woman who
Table 1
Seven statements on attitudes concerning use of contraceptive methods.
Statements Strongly Agree Neither agree Disagree Strongly
agree or disagree disagree
1) I am currently using a contraceptive 20.4% 17.3% 7.2% 12.3% 42.7% method but I do not trust it very much
to avoid pregnancy
2) My husband does not agree to 53.2% 7.2% 16.3% 5.1% 18.2% use condoms
3) A contraceptive method’s most 76.2% 12.5% 4.6% 3.9% 2.7% important attribute is its effectiveness
4) I don’t like taking the pill 55.7% 9.8% 7.2% 4.5% 22.8% because it makes me feel sick
5) The best contraceptive method 57.1% 16.6% 6.5% 9.4% 10.3% is sterilization because it never fails
6) I don’t believe that the pill is entirely 37.2% 21.3% 3.3% 11% 27.3% reliable in preventing pregnancy
Table 2
Statements by contraceptive use.
Pill FS Others Total p
1) I am currently using a contraceptive method but I do not trust it very much to avoid pregnancy
Agree 96 64 60 220 0.00005
40.7% 27.7% 51.7%
Neither agree or disagree 8 27 7 42
3.4% 11.7% 6%
Disagree 132 140 49 321
55.9 60.6% 42.2%
2) My husband does not agree to use condoms
Agree 148 142 62 352 < 0.005
62.7% 61.5% 53.4%
Neither agree or disagree 36 48 11 95
15.3% 20.8% 9.5%
Disagree 52 41 43 136
22% 17.7% 37.1%
3) The most important attribute of a contraceptive method is its effectiveness
Agree 216 201 100 517 < 0.01
91.5% 87% 86.2%
Neither agree or disagree 2 17 8 27
0.8% 7.4% 6.9%
Disagree 18 13 8 39
7.6% 5.6% 6.9%
4) I don’t like taking the pill because it makes me feel sick
Agree 119 179 84 382 < .00001
50.4% 77.5% 72.4%
Neither agree or disagree 3 21 18 42
1.3% 9.1% 15.5%
Disagree 114 31 14
48.3% 13.4% 12.1%
5) The best contraceptive method is sterilization because it never fails
Agree 163 190 77 430 < 0.001
69.1% 82.3% 66.4%
Neither agree or disagree 12 13 13
5.1% 5.6% 11.2%
Disagree 61 28 26
25.8% 12.1% 22.4%
6) I don’t believe that the pill is totally reliable in preventing pregnancy
Agree 132 156 53 341 < 0.001
55.9% 67.5% 45.7%
Neither agree or disagree 6 5 8 19
2.5% 2.2% 6.9%
Disagree 98 7 55 223
decides to discontinue her pregnancy. Most women, 66.8%, strongly disagreed with abor-tion, even if pregnancy was the result of con-traceptive failure. About 74% were aware that intentionally taking medication to terminate a pregnancy is tantamount to performing an abortion. The only circumstance in which abor-tion was acceptable to most women (69.1%) was in the case of risk to the woman’s life if the pregnancy were allowed to continue.
The above set of statements was merged in-to a single variable measuring attitudes in-towards abortion, with a maximum score of 40, a mini-mum of 8, and a mean of 17.7. Most respon-dents (59.4%) were against abortion, with 27.8% heavily against it and 31.6% less adamant. About 40.7% had less restrictive attitudes to-wards abortion. This ordinal variable was mea-sured against type of contraceptive used, age of respondent, age at sterilization, and marital
Table 3
Statement number 4 by age of respondent.
Age/Attitude <30 30 or > Total
Agree 144 237 381
57.6% 71.6%
Neither agree or disagree 18 23 41
7.2% 6.9%
Disagree 88 71 159
35.2% 21.5%
p = 0.0001
Table 4
Attitudes towards abortion.
Statements Strongly Agree Neither agree Disagree Strongly
agree or disagree disagree
1) If I got pregnant now it would be 72% 11.7% 6% 1.7% 8.6% a disaster to my life, but I would still
have the child
2) Abortion is a serious sin 82.8% 6.2% 4.5% 1.9% 4.6%
3) Abortion should be accessible 10% 7.6% 5.3% 7.9% 69.2% to every woman
4) Abortion should be accessible to 6.7% 9.3% 6% 11.2% 66.8% women in case of contraceptive failure
5) If I had an abortion I would not tell 22.6% 5.7% 10.6% 9.4% 51.6% my friends
6) Abortions should only be allowed 69.1% 13% 2.6% 4.5% 10.8% when the women’s life is at risk
7) A woman who takes a drug to terminate 74% 9.9% 2.2% 5.1% 8.7% a pregnancy is committing an abortion
status. Women using more effective methods (the pill, 48.4%, and sterilization, 37.5%) showed stronger attitudes against abortion than women using other methods (14.3%) (Table 5).
Statistically significant differences were found between the groups with different atti-tudes towards abortion and age at sterilization (Table 5). Among the women who were heavily against abortion, 22% had been sterilized at 24 or earlier. Meanwhile, among those who were less negative towards abortion, only 15.5% had been sterilized under the age of 24. Hence, the tendency to undergo sterilization earlier in life is associated with a more negative attitude to-wards abortion. Married and cohabiting women were more likely to be against abortion (60.5%) than those not cohabiting (45.8%), and this dif-ference was statistically significant (Table 5).
Discussion
The analysis of attitudes towards contraception showed that women using contraceptive meth-ods strongly emphasized the need for high rates
of effectiveness for their respective methods. This probably explains why most women con-sidered sterilization the best method. More than half (55%) trusted the contraceptive they were using, while most women (65.5%) reported side effects from taking the pill. Most sterilized women trusted sterilization more than women who were using the pill and other methods. This trend was greater among older women (over 30 years), while women on the pill trusted the method less than their peers who were steril-ized. This is probably related to contraceptive failure. Women on the pill demanded more ef-fectiveness from the method. Few sterilized women were undecided as to whether effec-tiveness was a contraceptive method’s most im-portant characteristic.
Proportionally more sterilized women re-ported side effects from the pill than did women actually using oral contraceptives. This may have been an important factor in their submitting to sterilization. In addition, more women on the pill disagreed with the state-ment that surgical sterilization was the best contraceptive method, while sterilized women
Table 5
Attitudes towards abortion by contraceptive use, age at sterilization, and by marital status.
By contraceptive use Pill Sterilization Others Total p
Strongly against 78 60 22 160 p< 0.005
48.4% 37.5% 14.3%
Against 65 82 35 182
35.5% 45.1% 19.7%
Fairly Acceptable 92 87 54 233
39.5% 37.3% 23.1%
By age at sterilization < 24 25 to 29 30 or > Total p
Strongly against 13 12 32 57 p= 0.001
22.8% 21.1% 56.1%
Against 5 35 42 82
6.1% 42.7% 51.2%
Fairly Acceptable 13 36 35 84
15.5% 42.9% 41.7%
By marital status Married Single Total p
Against 322 22 344 p= 0.05
60.5% 45.8%
Fairly Acceptable 210 26 236
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Acknowledgment
The data presented in this paper are taken partly from the author’s doctoral thesis entitled Regret After Female sterilization among low income women in São Paulo Brazil,which was approved by the Institute of Population Studies, University of Exeter, UK, in 1994. It is registered in the British Thesis Service of the British Library under number DX 182665, UK.
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The analysis of attitudes showed that abor-tion is generally not accepted, being consid-ered a serious sin. The only situation in which it was considered relatively acceptable was when there was a risk to the woman’s life if the pregnancy were allowed to continue. Attitudes against abortion are positively associated with the use of more effective methods and younger age at sterilization. Unmarried or non-cohabit-ing women were less negative towards abor-tion. This may relate to society’s views towards single parenthood.
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